Complaint Form

IDAHO DEPARTMENT OF FINANCE Securities Bureau 800 Park Blvd., Suite 200, Boise, ID 83712 P.O. Box 83720, Boise, ID 83720-0031 http://www.finance.idaho.gov Fax: 208/332-8099 208/332-8004 Toll Free within Idaho: 1-888-346-3378 E-mail: securities@finance.idaho.gov GUIDELINES FOR COMPLETING THE SECURITIES COMPLAINT FORM Before filling out the attached complaint form, please take the time to read these guidelines; they will help you understand our functions, and we will be better able to understand and act on your complaint. WHAT WE CAN DO: We investigate complaints against persons, business entities, and corporations accused of violating the licensing or anti-fraud provisions of laws administered by the Department. We are empowered to bring administrative or civil actions to stop these violations, and, in appropriate cases, to refer matters to the Prosecuting Attorneys' offices for criminal prosecution. WHAT WE CANNOT DO: We cannot act as a court of law, so we cannot order that monies be refunded, contracts be canceled or damages be awarded. If you have this type of problem, you should consult an attorney. We cannot give legal advice or act as your attorney. HOW YOU CAN HELP US: The purpose of this complaint form is to provide this Department with enough information to allow us to determine if an investigation into your allegations is warranted. Thus, it is important for you to furnish as much detailed information as possible. Documentary evidence is especially important, therefore, you should photocopy or scan all documents such as account statements, contracts, agreements, certificates, notes, trust deeds, correspondence, legible copies of the front and back of checks involved, escrow documents, advertising, etc., and attach them to the written complaint. (Please do not send originals; we cannot be responsible for their safekeeping.) How to submit complaint form and supporting documents: You may complete all sections of this fillable form, save, print and sign. Then scan and email it along with your scanned supporting documents to: securities@finance.idaho.gov or mail photocopied form and supporting documents to address below. Or You may print form, complete by hand (print clearly) and sign. Then mail along with your photocopied supporting documents to: Idaho Department of Finance Securities Bureau P.O. Box 83720, Boise, ID 83720-0031 or Express: 800 Park Blvd., Suite 200, Boise, ID 83712 If you have any questions concerning this form, you may contact the Securities Bureau at 208/332-8004. American LegalNet, Inc. www.FormsWorkFlow.com 2 COMPLAINT FORM INFORMATION ABOUT YOU A. Last Name First Middle Today's Date Home Address City State Zip Telephone Number Business Address City State Zip Telephone Number Email Address Trade or Occupation Age Marital Status Are you willing to be interviewed by an investigator from this office? Yes No Are you willing to be a witness if formal proceedings are commenced by the Idaho Department of Finance? Yes No SUBJECT OF COMPLAINT B. Company Name Address Telephone No. List persons who were involved in selling you the investment (please use separate pages to set forth any other available information about these persons.) Last Name First Middle Position Telephone No. Address City State Zip Last Name First Middle Position Telephone No. Address City State Zip American LegalNet, Inc. www.FormsWorkFlow.com 3 Please explain your previous investment experience with either the company or the salesperson who contacted you. Additionally, describe any personal relationships/dealings with the company or the salesperson. C. Questions About Your Investment: Yes No N/A If you used a broker, were investments in the account solicited, or recommended by the broker? Were trades made in your account without your authorization? Did you receive a prospectus, private placement memorandum, private offering memorandum, disclosure brochure, or any other disclosure document before making the investment? If a private investment opportunity, did you receive audited financial statements on the company? Did the person selling you the investment discuss the risks of the investment prior to purchase? Did you understand the risks of the investment? Do you feel the investment was in line with your investment goals? Did you have the financial ability to absorb the risk of the investment? Did you understand where your money was to be invested? If your investment was made from a brokerage account, did your account have a margin agreement? If you used a broker or investment adviser, did they have power of attorney or the authority to enter transactions in your account? American LegalNet, Inc. www.FormsWorkFlow.com 4 INFORMATION ABOUT INVESTMENT D. What did you purchase or invest in? (Examples: common stock, debenture, limited partnership interest, investment contract, fractional interests in an oil and gas lease). If available, include a copy of your most recent account statement. Date of Purchase Security No. of Shares Unit Price Total Price Date of Purchase Security No. of Shares Unit Price Total Price Date of Purchase Security No. of Shares Unit Price Total Price How was the amount paid: (lump sum, installments, other / check, cash, wire, other) Who received the payment from you? Did you pay by mail? To whom did you make your checks payable? (Please provide a copy of both sides of the check if possible) E. Did you sign or receive any type of contract? Yes No If yes, please enclose a copy. Where was it signed (city/county)? Were your securities delivered? Where are your securities held? If your securities have been delivered to you by mail, please attach a copy of the cover letter attached to your securities. F. How did you learn of the investment? (Check more than one if applicable and enclose copies of pamphlets or advertisements if available.) Personal visit Date Location Whom Telephone call Date From whom Where was the call received? American LegalNet, Inc. www.FormsWorkFlow.com 5 Advertising pamphlet/sales letter Sent to you at what address/location (If available, please include a copy of the pamphlet or letter) Newspaper Name of paper (If available, include a copy of the newspaper advertisement.) Date Radio Name of station Date Television Name of station Date Group Sales Presentation Date of presentation Where was presentation held? Other (Please Specify) G. List others who were present when the offers or sales were made to you. Name Address Telephone Relationship to Complainant Name Address Telephone Relationship to Complainant Name Address Telephone Relationship to Complainant H. Who else do you know that invested with the company, corporation, or association? Name Address Telephone Relationship to Complainant Name Address Telephone Relationship to Complainant Name Address Telephone Relationship to Complainant American LegalNet, Inc. www.FormsWorkFlow.com 6 I. Have you complained to subject or seller? Yes No If yes, what offer of adjustment or explanation was made? J. Have you notified or filed a complaint with any of the following agencies? If yes, please include a copy of your complaint. U.S. Securities and Exchange Commission Sheriff's Office Idaho Attorney General Local Police Dept. Other Federal Agency or Office Better Business Bureau County Prosecuting Attorney Local Newspaper K. Have you or any other victims filed a lawsuit in any court? Yes No If yes, please provide the name of the case/county/case number and provide a copy of the court documents L. In a brief statement, tell us the full story beginning with the date of your first contact to present. Keep dates of events in sequence and include misrepresentations. Be factual. Try to answer the questions "who", "what", "where" and "when." Attach extra sheets if more space is needed. American LegalNet, Inc. www.FormsWorkFlow.com 7 Signature (Please sign in ink) Date American LegalNet, Inc. www.FormsWorkFlow.com